Single Case Study of an Individual

Client Description.

The client is a 19-year-old single male who was referred for treatment by his parents who are concerned that his use of alcohol is interfering with his grades in college. The client reportedly had all A grades in high school and had been placed in a program for gifted students. However, he has reportedly flunked out of college in his first year. Following this he was also recently arrested for his second DUI offense, the first offense occurring when he was a senior in high school.

According to his parents, the client was born at full term with no complications occurring in the pregnancy and delivery of the baby. He met all of his developmental milestones ahead of expectation and has experienced no major health issues although his last physical examination was several years ago. He excelled in school and was placed in a program for gifted and talented students. According to his parents the client maintained an A average throughout high school even while being in a more challenging gifted program. He went to college with ambitions to go into chemical engineering, but "flunked out" after his first year, an event totally uncharacteristic of his past. His father is a neurosurgeon and his mother is a research scientist. Family history is significant for anxiety disorders in his father and both grandfathers and possible alcohol abuse in both grandfathers.

In addition, the client and his parents report that he has a history of experiences of anxiety and worry present over a three-year period. His parents report he has always been "high strung," but that he began to display physical signs of anxiety such as (dizziness, palpitations, etc.), cognitive signs (a strong sense of worry over his everyday life issues), and behavioral signs (few social contacts, missing school, etc.) while in high school. The anxiety that the client experiences is not limited to specific or discrete situations and does not appear to consist of panic attacks (although this is also a consideration; American Psychiatric Association [APA], 2000). His parents described him as a "functional alcoholic" and that they were unsure if his drinking behaviors occurred before or after his difficulties with anxiety; however, they do know he was drinking alcohol regularly while he was in high school.

B. Assessment

The client's parents contacted the clinic for treatment for their son for his difficulties with suspected alcohol abuse. Both the client and the client's parents (with the permission of the client) participated in a standard clinical interview process designed to coincide with the diagnostic criteria from the DSM -- IV -- TR for axis I and axis II disorders.

The client agreed to enter treatment for issues with anxiety and substance abuse. Both the client and the therapist discussed the goals of treatment for the client. These included designing a program to manage the client's anxiety, attending AA meetings, and individual therapy and that helping the client control his anxiety and his use of alcohol. In addition, the client expressed a wish to return back to school and later sessions will be devoted to specific issues with college, anxiety, and methods of coping with the pressures of college designed specifically for the client.

C. Measurement.

The client underwent a clinical interview that investigated the presence of any DSM -- IV -- TR axis I or axis II disorders. In addition, the counselor plans to administer the Structural Clinical Interview for the DSM (SCID-1 and SCID-2; First, Spitzer, Gibbons, Williams, & Benjamin, 1996; First, Spitzer, Gibbons, & Williams, 1997) for further clarification and quantification of these issues. The SCID-1 and 2 are semi-structured clinical interviews to determine DSM diagnoses on axis I or axis II. The SCID for the new DSM-5 is not yet available, so the DSM-IV-TR was used in this case. In addition to this data a thorough and complete history will be taken regarding the onset of the client's drinking and onset of his difficulties with anxiety in order to determine as best as possible which one preceded the other. This information will be used to determine the focus of treatment (anxiety or substance abuse). The preliminary results of the clinical interview resulted in the following DSM -- IV -- TR diagnosis:

Axis I: 300.02. Generalized Anxiety Disorder

305.00. Alcohol Abuse

Axis II: V71.09. No diagnosis on Axis II

Axis III: No significant medical issues.

Axis IV: Two DUI arrests; flunked out of college; reports feeling isolated from friends and family.

AXIS V: GAF = 51-55. Symptoms of impaired social and interpersonal relationships. Alcohol Abuse. Severe symptoms of anxiety.

The client agreed to maintain a behavioral journal to document the daily instances where he feels anxious in order to establish a baseline with which to judge the effectiveness of the treatment program for his anxiety. The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) will be used to monitor the client's level of anxiety over the weeks in treatment ad following treatment. This is a 21-question multiple-choice self-report inventory that measures the severity of an individual's anxiety (Beck et al., 1988). Likewise, the client will also maintain a journal of his drinking behavior in an effort to determine a baseline and to use as a barometer to judge the effectiveness of interventions aimed at his drinking.

D. Research Evaluation Design

The design of the study is a single -- case qualitative design. As there is only one client with these particular issues being studied this is believed to be the best possible research evaluation design for this particular issue. The questions in section 1.3 will be addressed as well as ascertaining whether the patient began drinking alcohol in high school in an effort to self-medicate for his anxiety or whether his anxiety worsened after he began drinking.

E. Intervention or Treatment.

One issue not yet discussed is the possibility that the client may have a medical condition (e.g., a cardiac condition) that is producing his anxiety. There are many medical conditions that can mimic anxiety disorders (Sadock & Sadock, 2007). The client has not had a full physical evaluation for several years and it would be prudent for the client to have such an evaluation.

In terms of treatment and cognitive behavioral psychotherapy (CBT) techniques have been demonstrated to be useful in treating anxiety and would be the first choice in this case followed by some insight-oriented techniques if it is discovered that there are developmental issues that contribute to his presentation (Covin, Ouimet, Seeds, & Dozois, 2008). This client can also be referred to a psychiatrist for medical management of his anxiety. Typically selective serotonin reuptake inhibitors, benzodiazepines, or other medications can be effectively used in clients who have generalized anxiety disorder (Sadock & Sadock, 2007). The combination of counseling/psychotherapy and medication can be an effective approach if indeed the client does have generalized anxiety disorder and not some physical problem that is producing or contributing to his anxiety and worry.

A number of problems, such as substance abuse, that are addressed in psychotherapy are related to lifestyle factors. Changing ingrained and nearly habitual behaviors can be quite difficult and require considerable effort and motivation on the part of the person who wishes or needs to change, such as a person that has developed a tendency to self-medicate anxiety with drinking alcohol. Traditionally physicians and even many psychotherapists encourage change through a combination of advice and insight, often using more direct forms of persuasion. The evidence that offering advice as a means to help a person change a detrimental behavior is not encouraging with only 5 to 10% success rates reported for traditional therapeutic modes for substance abuse or substance dependence (Rollnick, Kinnersley, & Stott, 1993). Using a direct method of advice opens the potential for clients to become even more resistance to changing potentially disruptive behaviors that have perceived subjective utility on part of the client (Rollnick, Kinnersley, & Stott, 1993). Motivational interviewing (MI) evolved from patient -- centered approaches to address this issue. Using MI combined with CBT would be an effective combination to address both the issues of alcohol abuse and anxiety (Rubak, Sandbaek, Lauritzen, & Christensen, 2005).

Finally, the client will be asked to attend a minimum of two meetings with local Alcoholics Anonymous (AA) groups. There is solid evidence that group therapy can be an important intervention for substance abuse and substance dependence and AA meetings, while are not empirically validated, can supplement individual counseling sessions for clients with substance abuse and comorbid psychological issues (Dutra, Stathopoulou, Basden, Leyro, Powers, & Otto, 2008).

F. Monitoring Progress and Post -- Intervention Data Collection.

Initial diagnostic considerations for the client will be confirmed using the SCID-1 and SCID-2. The BAI (Beck et al., 1988) as well as the client's daily anxiety journal can be used to monitor and record his progress in dealing with his anxiety is intervention continues. The client's journal will also be used to monitor his progress at reducing his intake of alcohol and the counselor will sent request that the client keep a record of his attendance and AA and present these attendance sheets during each session in order to monitor his AA attendance. In order to get more in-depth information regarding the client's progress the client's parents can also be interviewed regarding their perception of their son's progress.

Post-intervention the client can be contacted at four weeks, eight weeks, six months, and one year and given a standard clinical interview along with the Beck Anxiety Inventory in order to determine how well he has been able to manage his issues.

G. Definition of Practice of Effectiveness.

Since this is a qualitative study the measurement of how effective the interventions work will rely heavily on the self-report of the individual. However, interviews with the parents can provide more objective information. With respect to the client's drinking, the definition of effectiveness can rely on the clients self-report regarding the number of drinks consumed and a reevaluation of his substance abuse at the completion of treatment, six months post-treatment, and one-year post-treatment using DSM -- IV -- TR criteria for substance abuse and the SCID-1 if needed.

Information regarding the change in anxiety levels can also be directly taken from the BAI administered at specific intervals. The definition of effectiveness can depend on the categorical level of anxiety the client demonstrates on the BAI (e.g., dropping from moderate levels of anxiety to mild levels of anxiety and remaining at the mild level for several consecutive weeks). The categories of anxiety severity based on BAI scores are (Beck et al., 1988):

0-7: minimal level of anxiety

8-15: mild anxiety

16-25: moderate anxiety

26-63: severe anxiety

Thus, the BAI can provide a good measure of the client's issues with anxiety.

H. Data Analysis

Since this is a qualitative study no statistical analyses will be performed. Instead most of the data will be looked at in terms of the descriptions of both the client and his parents regarding his progress, number of drinks consumed, severity of anxiety, and number of episodes of anxiety that occur over the course of treatment. Compliance with AA will be measured by attendance sheets and qualitative information obtained from counseling sessions. Client data will be gathered weekly; data from the parents will be gathered pre -- and post-treatment and at specific post -- treatment follow-up times.

I. Limitations of the Evaluation Study.

There are several limitations to this study:

1. The study only uses a single participant, thus generalizability is limited.

2. The study relies heavily on self-report data which can be unreliable and requires the single participant to be candid.

3. There may be several interventions going on at the same time including treatment for anxiety or substance abuse and AA. It is impossible to tell which treatment(s) are actually being effective here.

4. The study will utilize data from the client and the client's parents and this data may not coincide. Moreover, the parents may not have a realistic view of what is going on with their son.

5. The study cannot determine which disorder came first: GAD or substance abuse. It must rely on the self-report of the client to postulate this relationship. Moreover, the study cannot infer that one disorder caused the other to occur as it is correlational nature.